Median Marketplace Deductible only $850

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Marketplace Enrollees are in Plans with Lower Deductibles, More Covered Health Services than Commonly Understood

Consumers enrolled in a 2016 Health Insurance Marketplace plan have moderate deductibles and access to a number of covered health services before reaching the deductible, according to a new analysis released today by the Centers for Medicare & Medicaid Services (CMS). The median individual deductible is $850 for Healthcare.gov Marketplace policies, and consumers’ plans have an average of seven covered services before the deductible.

“This report shows that Marketplace plans are providing consumers with real financial protections and access to important health services,” said Health Insurance Marketplace CEO Kevin Counihan. “As with premiums, Marketplace deductibles and out-of-pocket costs in Marketplace plans are often lower than advertised thanks to the financial help available. And most plans cover common health services, like primary care visits and generic drugs, with no or low cost-sharing before consumers meet their deductibles.”

A health plan’s deductible is the amount the consumer needs to pay for certain health care services before the health insurance plan begins to pay. Deductibles can be an important factor in an individual’s plan choice. This year, HealthCare.gov implemented new tools such as an out-of-pocket cost calculator and doctor lookup function to help consumers find a plan that meets their needs and budget. The analysis released today takes into account the fact that about 60 percent of Marketplace consumers receive financial assistance that reduces their deductibles, and other cost sharing obligations. The median Marketplace deductible decreased from 2015 to 2016.

In addition, all Marketplace plans cover certain preventive services such as cancer screenings, immunizations and well-child visits without cost-sharing. Most plans also cover other commonly used health services either without cost-sharing or with low copayments, even if a consumer has not met the deductible. This means that even though a health plan has a deductible, many consumers face no or low cost sharing for the services they use frequently.  Nationally, Marketplace plans cover an average of seven types of services before the deductible, most commonly prescription drugs, primary care or specialist visits, and outpatient mental health services.

These findings on the moderate cost-sharing levels in Healthcare.gov Marketplace plans are consistent with other data showing that Marketplace policies are providing consumers with access to care and financial protection. For example, Marketplace consumers report accessing health services, including check-ups, physician services, and prescription drugs, at rates similar to consumers with employer-sponsored coverage.  Nationally, median out-of-pocket costs (taking into account premiums, deductibles, and other cost sharing) for consumers purchasing health coverage through the individual market fell by 25 percent between 2013 and 2014, when the Health Insurance Marketplace and other individual market reforms in the Affordable Care Act took effect.

To read the full report, please visit the CMS website at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-12.html

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